UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts

Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Venous thromboembolism in patients with surgically treated ankle fractures

OBJECTIVES

In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70 years of age, and had an isolated injury.

INTERVENTION

Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture.

MAIN OUTCOME MEASUREMENTS

Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union.

RESULTS

There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups.

CONCLUSIONS

No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Prevalence of Preoperative Lower Extremity Deep Vein Thrombosis in Bilateral Calcaneal Fractures

There are no studies on epidemiologic characteristics of deep vein thrombosis (DVT), when specified at in patients with bilateral calcaneal fractures. This study aimed to address the preoperative DVT in bilateral calcaneal fractures. Between October 2014 and December 2018, adult patients presenting with bilateral calcaneal fractures and having preoperative Duplex ultrasound (DUS) of bilateral lower extremities for detection of DVT were included. Their medical data were collected, with regards to demographics, comorbidities, injury-related data and biomarkers. Baseline characteristics between patients with and without DVT were compared using bivariate tests. The further multivariate logistics regression analysis was conducted to identify independent factors associated with DVT. In total, 258 patients with bilateral calcaneal fractures were included, with 21 (8.1%) having preoperative DVT, diagnosed at 7.7 ± 4.2 days after injury. The prevalence rate of proximal DVT was 1.9% and of distal DVT was 6.2%. Thirty five thrombi were found, with 6 (17.1%) in proximal veins and 29 (82.9%) in distal veins. Nine patients had DVTs in multiple veins, and 2 patients had bilateral DVTs. The multivariate analyses showed history of allergy (odds ratio [OR] = 2.17), concurrent other fractures (OR = 4.53), prolonged time since injury (for each day, OR = 1.16), elevated plasma D-dimer level (≥1.73 vs <1.73 mg/L, OR = 3.74) and reduced albumin level (<34.2 g/L vs ≥34.2 g/L, OR = 2.92) were independent factors associated with DVT. Multiple factors were identified to be associated with DVT and greater consideration should be given to the use of pharmacologic prophylaxis in patients involving these factors, to reduce DVT occurrence.

Incidence and risk factor for preoperative deep vein thrombosis (DVT) in isolated calcaneal fracture, a prospective cohort study

BACKGROUNDS

Deep vein thrombosis (DVT) occurring during the preoperative waiting period may affect the prognosis of traumatic patients, but there still lack of relevant data. This study aimed to address the preoperative DVT in isolated calcaneal fractures.

METHODS

Patients who presented with isolated calcaneal fracture and received preoperative Duplex ultrasound scanning of bilateral lower extremities for detection of DVT between October and December 2018 were eligible for inclusion. Relevant data were prospectively collected, including demographics, comorbidities, lifestyles, injury, and laboratory biomarkers at admission. Univariate analyses were used to compare the difference of each variable between patients with and without DVT. Multivariate logistics regression analysis was used to identify the independent risk factors for DVT.

RESULTS

Totally, 770 patients met the criteria and were included, and 24 (3.1%) had preoperative DVT diagnosed at mean of 5.3 days after injury, all of which were asymptomatic. Among patients with DVTs, 36 thrombi were found and 29 (80.6%) were in distal veins. Eight patients had DVTs in multiple veins, but no patients had bilateral DVTs. The multivariate analyses showed older age (≥58 vs <58 years, OR = 3.84), delay from injury to DUS (in each day, OR = 1.23) and elevated plasma D-dimer level (≥1.79 vs <1.79 mg/L, OR = 2.53) were independent risk factors associated with DVT.

CONCLUSIONS

Due to low prevalence of DVT in isolated fracture, routine throboprophylaxis is not recommended. However, emphasis should be given in older patients with delay to admission and elevated plasma D-dimer level for targeted detection of DVT and rapid therapeutic intervention.

Venous thromboembolism in trauma patients with lower limb cast immobilization, associated risk reduction and complication using rivaroxaban

INTRODUCTION

Several studies have shown a reduction in the rate of thromboembolic events with LMWH thromboprophylaxis in patients immobilised in lower limb cast. However, the literature is limited on the use of rivaroxaban in this setting. Therefore the aim of this study was to assess the associated impact of rivaroxaban on the incidence of venous thromboembolism in trauma patients with lower limb cast immobilisation.

METHOD

Adult patients treated with lower limb cast immobilisation for different types of lower limb injuries were included in this study. One cohort of patients (n = 518) received rivaroxaban thromboprophylaxis. This was compared with a historical cohort (n = 486), who received no rivaroxaban for thromboprophylaxis.

RESULTS

The number of patients developing VTEs in the rivaroxaban group was zero, compared with 6 cases (1.2%) in the nonrivaroxaban group p = 0.013. There were no major or minor bleeding incidences; no wound complications reported in the rivaroxaban group. All the side effects reported in association with rivaroxaban use did not require further intervention.

CONCLUSION

This study has shown that rivaroxaban is associated with a significant reduction in the risk of VTEs in patients with lower limb cast immobilisation without increasing the risk of bleeding or associated untoward effect. Lower limb immobilisation is high risk factor for VTE per se. However, there is still limited data in the literature to make further recommendations.

Venous Thromboembolic Prophylaxis in Foot and Ankle Surgery: A Review of Current Literature and Practice

Venous thromboembolism (VTE) is a well-known and feared complication following foot and ankle surgery, as it is a source of morbidity and mortality in the perioperative phase. The most recent CHEST guidelines recommended against the use of chemoprophylaxis and the majority of the literature has found a low incidence of VTE following foot and ankle surgery. Some authors prefer screening patients for risk factors and recommend the use of chemoprophylaxis on a case-by-case basis. Interestingly, studies that found high incidence of VTE were unable to determine a statistically significant difference between the prophylaxis and placebo groups. Major limitations of retrospective reviews is they are only able to study symptomatic VTE because no routine screening is typically performed. In a survey study, up to 98% of foot and ankle surgeons responded that they use prophylaxis in high-risk patients. Despite evidence-based recommendations, a significant number of foot and ankle surgeons are routinely using some form of VTE prophylaxis without taking risk factors into account.

LEVELS OF EVIDENCE

Clinical, Level IV: Review Article.

Incidence of Preoperative Deep Vein Thrombosis in Calcaneal Fractures

OBJECTIVES

This study examined the incidence and risk factors of preoperative deep vein thrombosis (DVT) in patients presenting to an outpatient setting with an isolated calcaneal fracture.

DESIGN

Retrospective chart review.

SETTING

All patients included in the study presented to the treating surgeon at a Level I trauma center with isolated calcaneal fractures as an outpatient between 2005 and 2013.

METHODS

These patients were either referred from outside hospitals, had been evaluated in the emergency department initially and presented for definitive care, or presented initially to the outpatient clinic. Patients included were over the age of 18, had a preoperative duplex ultrasonography of bilateral lower extremities per the treating surgeon's protocol, and had at minimum 6 weeks follow-up. Patients were excluded if they were a polytrauma, had a documented hypercoagulable state, or were on baseline pharmacologic anticoagulation for another condition. All patients had a preoperative duplex ultrasound of both lower extremities to evaluate for DVT at least 7 days after injury.

MAIN OUTCOME MEASURE

Patients found to have a preoperative DVT were compared with those who did not have preoperative DVT for possible risk factors.

RESULTS

One hundred fifty-nine patients qualified for our study and of these, 19 (12%) were found to have a DVT preoperatively, almost all of which were in distal veins. All risk factors, including age, sex, and body mass index were analyzed as continuous variables. Older age was found to be a risk factor for DVT (P = 0.009, Odds Ratio = 1.06, 95% CI, 1.01-1.11). All other predictor variables, including body mass index (P = 0.05) and sex (P = 0.08), were not statistically significant predictors in our sample.

CONCLUSIONS

The incidence of preoperative DVT found here is almost 2 times as high as any previously published examination of lower extremity injuries. Physicians should be aware of this increase so they may counsel patients about the risks of DVTs and the likelihood of any sequelae from developing a DVT that may affect a patient's recovery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The efficiency of O-(beta-hydroxyethyl)-rutosides in reducing the incidence of superficial venous insufficiency in patients with calf muscle pump dysfunction

Objective We aimed to evaluate the efficiency of O-(beta-Hydroxyethyl)-rutosides (Oxerutin) in reducing the incidence of venous system disease among patients with calf muscle pump dysfunction secondary to immobilization due to lower-limb fractures. Methods A total of 60 patients with lower-limb fractures and immobilized in plaster casts were included in this study randomized into control (n = 30; mean: 30.37 ± 6.03 years; 73.3% males; no treatment) and experiment (n = 30; mean: 31.67 ± 4.76 years; 66.6% males; Oxerutin, 500 mg po q12hr) treatment groups. Doppler ultrasound was performed to evaluate the effect of oxerutin on the alterations in the venous circulation. Results Patients in the control group were determined to be more commonly affected from the below-knee immobilization in terms of venous dysfunction in the great saphenous vein in the below-knee region when compared with the patients in the oxerutin treatment group (46.7 vs. 13.3%, respectively; p = 0.011). Incidence of reflux in the small saphenous vein was more common in the control group during the healing period when compared with the experiment group (40.0 vs. 10.0%, respectively; p = 0.017). None of the patients developed venous thrombosis. Conclusions In conclusion, the impairment of the lower extremity muscle pump should be considered as an important risk factor for venous disease, and should be evaluated. O-(beta-Hydroxyethyl)-rutosides during 6-8 week cast immobilization for a lower limb fracture may be an effective prophylactic regimen in reducing the incidence of reflux in the below-knee superficial veins.

Oral thromboprophylaxis in patients with ankle fractures immobilized in a below the knee cast

BACKGROUND

Lower-limb immobilization has been implicated as an etiologic factor for a venous thromboembolism (VTE). Most of the current literature encourages the use of thromboprophylaxis with injectable low-molecular-weight heparin (LMWH) in trauma patients. Injectable anticoagulants have inherent problems of producing pain and bruising. They are also difficult to administer, leading to low compliance. Oral anticoagulants are therefore gaining popularity for use as thromboprophylactic agents in hip and knee arthroplasty patients. There are not enough studies in the literature, however, to support their use in ambulatory trauma patients whose ankle fractures are being managed nonoperatively on an outpatient basis.

METHODS

This study evaluated the efficacy of oral anticoagulants for preventing VTE in ambulatory trauma patients who required temporary lower limb immobilization for non-operative management of their ankle fractures. A total of 200 consecutive patients who presented to the fracture clinic with an ankle fracture that was managed in a plaster cast were included in this study. These patients were assessed for risk of developing VTE and high risk patients were administered an oral anticoagulant to prevent VTE.

RESULTS

There was only one case of an isolated distal DVT among the 200 patients.

CONCLUSIONS

This study shows that an oral anticoagulant was a safe alternative to injectable LMWH as a thromboprophylactic agent for ambulatory trauma patients requiring temporary lower limb immobilization for non-operative management of an ankle fracture.

Prevalence of Acute Deep Vein Thrombosis in Patients with Ankle and Foot Fractures Treated with Nonoperative Management-A Pilot Study

The prevalence of deep vein thrombosis (DVT) among patients with ankle and foot fractures in Australia treated nonsurgically is unknown. Indications for thromboprophylaxis screening and management are unclear. The primary outcome was the prevalence rate of DVT among nonsurgically managed ankle and foot fracture patients. Patients were enrolled into a prospective cross-sectional pilot study at an outpatient hospital fracture clinic. DVT risk factors and symptoms were recorded at time of recruitment followed by referral for compression duplex ultrasonography. Independent t-test and Fisher exact test were used to assess the significance of these variables with DVT. A total of 72 patients were included in the final analysis. Overall, 11% (8/72) of patients had DVT-seven distal DVTs and one proximal DVT. Four were symptomatic including the patient with a proximal thrombus. In comparison, the majority of patients were asymptomatic of DVT (63/72). A significant risk factor found to be associated with DVT was age ≥ 45 (p = 0.013) years, and a lack of symptoms (p = 0.006) was associated with no DVT. This pilot study is the first in Australia to investigate the prevalence of DVT in this specific subgroup of patients. We found a prevalence of 11% of DVT in a small group of patients with age ≥ 45 years, being the only significant associated risk factor. Future larger scale prospective studies are warranted to confirm these results.

Understanding risks and complications in the management of ankle fractures

Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.

Neuromuscular electrostimulation viathe common peroneal nerve promotes lower limb blood flow in a below-kneecast: A potential for thromboprophylaxis

Objectives

We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.

Methods

This is an open-label physiological study on ten healthy volunteers. Duplex ultrasonography of the superficial femoral vein measured normal flow and cross-sectional area in the standing and supine positions (with the lower limb initially horizontal and then elevated). Flow measurements were repeated during activation of the geko stimulator placed over the peroneal nerve. The process was repeated after the application of a below-knee cast. Participants evaluated discomfort using a questionnaire (verbal rating score) and a scoring index (visual analogue scale).

Results

The geko device was effective in significantly increasing venous blood flow in the lower limb both with a plaster cast (mean difference 11.5 cm/sec^-1; p = 0.001 to 0.13) and without a plaster cast (mean difference 7.7 cm/sec^-1; p = 0.001 to 0.75). Posture also had a significant effect on peak venous blood flow when the cast was on and the geko inactive (p = 0.003 to 0.69), although these differences were less pronounced than the effect of the geko (mean difference 3.1 cm/sec^-1 (-6.5 to 10)). The geko device was well tolerated, with participants generally reporting only mild discomfort using the device.

Conclusion

The geko device increases venous blood flow in the lower limb, offering a potential mechanical thromboprolylaxis for patients in a cast.

Cite this article: Bone Joint Res 2013;2:179–85.